The Doctor's Dilemma

CARL T.ROWAN

April 16, 1991|By CARL T. ROWAN

WASHINGTON. — If you were a poor woman in Louisiana and had a baby by normal delivery, your doctor would have been reimbursed $330 by Medicaid in 1989. Private insurers in that state paid an average of $860 to doctors for the same delivery.

If you were a heart patient in New York, your doctor would have received just $15 from Medicaid for an electrocardiogram. He would have been reimbursed nearly triple that by Medicare for the same procedure.

If you were a doctor, which of those patients would you least prefer to see -- the one covered by private insurance, the one with Medicare or the one whose bills are reimbursed by Medicaid?

Unless you possess the selfless devotion of a Mother Teresa, or the math skills of a preschooler, the answer clearly is the Medicaid patient, who brings such relatively low fees.

Medicaid is the federal-state health-insurance program covering 27 million low-income Americans, nearly half of them children. States have a good deal of leeway in setting the fees paid to doctors, and the amounts vary widely from state to state. A report to Congress from the federal Physician Payment Review Commission says that, on average across the nation, Medicaid pays doctors only 69 percent of the fees paid by Medicare, the insurance program for the elderly, and an even smaller percentage of what private insurers pay.

Doctors are not required to take Medicaid or Medicare patients. They can often make a profit on Medicare patients, since fees, which are set by the federal government, generally are close to market rates. But in some states they may lose money on certain services under Medicaid.

The review commission found that 44 states reported problems getting doctors to take part in Medicaid. The situation is especially bad in inner cities and rural areas, where the need is greatest because the indigent population is highest.

As a result, Medicaid beneficiaries are not as likely to have access to ''mainstream care'' in private doctors' offices. This pushes them toward public hospital emergency rooms and outpatient departments, or community clinics. As I reported recently, public hospitals are overcrowded and under-equipped.

With more than 30 states facing budget shortfalls this year, there's little hope that Medicaid will get a major influx of money. The program already takes an ever-increasing share of state funds. According to the National Governors' Association, 14 percent of overall state budgets went to Medicaid last year, compared with 9 percent in 1980. State spending on the program increased a whopping 18.4 percent last year and is expected to soar another 25 percent this year.

Moreover, many politicians and health-care experts contend that raising doctors' fees may not really benefit poor people. For one thing, states may tighten Medicaid eligibility rules to recoup the extra expenditures. Also, it's noted that there already is a federal law requiring states to pay doctors enough to guarantee that Medicaid recipients have as much access to services as the rest of the population. But the rule has not been enforced.

A lot of doctors simply don't want to handle Medicaid patients. Besides low fees, they say they are discouraged by high malpractice premiums, complex billing procedures and failure of patients to follow treatment plans. In addition, many low-income patients find that even if doctors are available, other hindrances, such as lack of transportation, keep them from going to the offices.

States are looking at other ways to attract doctors to Medicaid -- simplified billing procedures, more rapid reimbursement, incentive payments for providers in medically underserved areas. Some also have set up toll-free hotlines to help citizens locate Medicaid doctors and are trying to improve alternatives like public hospitals.

Governors are pleading for Congress to restructure Medicaid and create a ''new and real partnership'' between the states and Washington for the design and delivery of the program. We may have to have that kind of major overhaul to make Medicaid the vital element of America's health-care system that it was meant to be.